PF4-heparin antibodies during ECMO: incidence, course, and outcomes

Laverdure, Florent; Louvain-Quintard, Virginie; Kortchinsky, Talna; Rézaiguia-Delclaux, Saïda; Imbert, Audrey; Stéphan, François

doi:10.1007/s00134-016-4262-2

Cited by 15 publications

(15 citation statements)

References 5 publications

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“…However, tests required to diagnose HIT in ECMO patients are rarely performed, indicating that actual HIT rate in ECMO patients is highly underestimated and sometimes an approach to "diagnose" HIT is to switch to an alternative anticoagulant like Argatroban or Bivalirudin based on clinical suspicion and low platelet count [28,29,31]. In our review, seven studies report a confirmed diagnosis of HIT through laboratory tests [6,8,28,31,34,36,39]. All of them declared HIT occurrence as a primary outcome.…”

Section: Discussionmentioning

confidence: 99%

Platelets and extra-corporeal membrane oxygenation in adult patients: a systematic review and meta-analysis

et al. 2020

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Despite increasing improvement in extracorporeal membrane oxygenation (ECMO) technology and knowledge, thrombocytopenia and impaired platelet function are usual findings in ECMO patients and the underlying mechanisms are only partially elucidated. The purpose of this meta-analysis and systematic review was to thoroughly summarize and discuss the existing knowledge of platelet profile in adult ECMO population. All studies meeting the inclusion criteria (detailed data about platelet count and function) were selected, after screening literature from July 1975 to August 2019. Twenty-one studies from 1.742 abstracts were selected. The pooled prevalence of thrombocytopenia in ECMO patients was 21% (95% CI 12.9-29.0; 14 studies). Thrombocytopenia prevalence was 25.4% (95% CI 10.6-61.4; 4 studies) in veno-venous ECMO, whereas it was 23.2% (95% CI 11.8-34.5; 6 studies) in veno-arterial ECMO. Heparin-induced thrombocytopenia prevalence was 3.7% (95% CI 1.8-5.5; 12 studies). Meta-regression revealed no significant association between ECMO duration and thrombocytopenia. Platelet function impairment was described in 7 studies. Impaired aggregation was shown in 5 studies, whereas loss of platelet receptors was found in one trial, and platelet activation was described in 2 studies. Platelet transfusions were needed in up to 50% of the patients. Red blood cell transfusions were administered from 46 to 100% of the ECMO patients. Bleeding events varied from 16.6 to 50.7%, although the cause and type of haemorrhage was not consistently reported. Thrombocytopenia and platelet dysfunction are common in ECMO patients, regardless the type of ECMO mode. The underlying mechanisms are multifactorial, and understanding and management are still limited. Further research to design appropriate strategies and protocols for its monitoring, management, or prevention should be matter of thorough investigations.

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Section: Discussionmentioning

confidence: 99%

Platelets and extra-corporeal membrane oxygenation in adult patients: a systematic review and meta-analysis

et al. 2020

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“…We counted the number of medications given that could potentially cause thrombocytopenia (see Supplementary Methods), but we did not include heparin because all subjects received heparin. We evaluated subjects for heparin-induced thrombocytopenia (HIT) when it was suspected (see Supplementary Methods) [23-25]. Comorbid conditions were quantified with the Charlson Index [26].…”

Section: Methodsmentioning

confidence: 99%

Thrombocytopenia and extracorporeal membrane oxygenation in adults with acute respiratory failure: a cohort study

et al. 2016

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Purpose The association between extracorporeal membrane oxygenation (ECMO) use and the development of thrombocytopenia is widely presumed yet weakly demonstrated. We hypothesized that longer duration of ECMO support would be independently associated with worsened thrombocytopenia. Methods We performed a single-center retrospective cohort study of 100 adults who received ECMO for acute respiratory failure. We used generalized estimating equations to test the association between days on ECMO and daily percentage of platelets compared to the first post-cannulation platelet count. We constructed a multivariable logistic regression model with backwards stepwise elimination to identify clinical predictors of severe thrombocytopenia (≤ 50,000/μL) while on ECMO. Results Days on ECMO was not associated with a decrease in platelet count in the unadjusted analysis (β: -0.85, 95% CI: -2.05 to 0.36), nor after controlling for days hospitalized prior to ECMO, APACHE II score, platelet transfusions, and potential thrombocytopenia-inducing medications (β: -0.85, 95% CI: -1.9 to 0.22). Twenty-two subjects (22%) developed severe thrombocytopenia. The APACHE II score and platelet count at the time of cannulation predicted the development of severe thrombocytopenia. The odds of developing severe thrombocytopenia increased 35% for every 5-point increase in APACHE II score (OR 1.35, 95% CI: 0.94 to 1.94), and increased 35% for every 25,000/μL platelets below a mean at cannulation of 188,000/μL (OR 1.35, 95% CI: 1.10 to 1.64). Conclusions Duration of ECMO is not associated with the development of thrombocytopenia. The severity of critical illness and platelet count at the time of cannulation predict the development of severe thrombocytopenia while receiving ECMO for respiratory failure. Future studies should validate these findings, especially in cohorts with more venoarterial ECMO patients, and should characterize the association between thrombocytopenia and bleeding events while on ECMO.

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“…Suspicion of HIT was raised in patients on ECLS by various factors including a decrease in platelet count by >50% (5-9), thrombotic event(s) (6,9,10), change in postoperative status (6), duration of ECLS support >72 hours (11) and intermediate to high 4Ts score (>3) (6,12). The cutoff criterion for HIT suspicion was not always specified or uniform for every institution.…”

Section: Definitionsmentioning

confidence: 99%

“…However, thrombocytopenia in critically ill patients is often multifactorial and may be due to various inciting events making it difficult to distinguish HIT from non-HIT thrombocytopenia in patients on ECLS (12). Common causes of thrombocytopenia that mimic the presentation of HIT (28,30) include circuit related effects of mechanical circulatory support causing platelet activation and aggregation (26,31), sepsis, medications, surgery, bleeding, hemodilution, intravascular devices and blood transfusions (11).…”

Section: Ecmomentioning

confidence: 99%

Heparin-induced thrombocytopenia during extracorporeal life support: incidence, management and outcomes

Choi

Luc

Weber

et al. 2019

Ann. Cardiothorac. Surg.

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Background: Heparin-induced thrombocytopenia (HIT) is a severe antibody-mediated reaction leading to transient prothrombosis. However, its incidence in patients on extracorporeal life support (ECLS) is not well described. The aim of this systematic review was to report the incidence of HIT in patients on ECLS, as well as compare the characteristics and outcomes of HIT in patients undergoing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and veno-venous ECMO (VV-ECMO). Methods: An electronic search was performed to identify all studies in the English literature examining outcomes of patients with HIT on ECLS. All identified articles were systematically assessed using specific inclusion and exclusion criteria. Random effects meta-analysis as well as univariate analysis was performed. Results: Of 309 patients from six retrospective studies undergoing ECLS, 83% were suspected, and 17% were confirmed to have HIT. Due to the sparsity of relevant retrospective data regarding patients with confirmed HIT on ECLS, patient-based data was subsequently collected on 28 patients from case reports and case series. Out of these 28 patients, 53.6% and 46.4% of them underwent VA-ECMO and VV-ECMO, respectively. Patients on VA-ECMO had a lower median platelet count nadir (VA-ECMO: 26.0 vs. VV-ECMO: 45.0 per µL, P=0.012) and were more likely to experience arterial thromboembolism (VA-ECMO: 53.3% vs. VV-ECMO: 0.0%, P=0.007), though there was a trend towards decreased likelihood of experiencing ECLS circuit oxygenator thromboembolism (VA-ECMO: 0.0% vs. VV-ECMO: 30.8%, P=0.075) and thromboembolism necessitating ECLS device or circuit exchange (VA-ECMO: 13.3% vs. VV-ECMO 53.8%, P=0.060). Kaplan-Meier survival plots including time from ECLS initiation reveal no significant differences in survival in patients supported on VA-ECMO as compared to VV-ECMO (P=0.300). Conclusions: Patients who develop HIT on VA-ECMO are more likely to experience more severe thrombocytopenia and arterial thromboembolism than those on VV-ECMO. Further research in this area and development of standardized protocols for the monitoring, diagnosis and management of HIT in patients on ECLS support are warranted.

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PF4-heparin antibodies during ECMO: incidence, course, and outcomes

Cited by 15 publications

References 5 publications

Platelets and extra-corporeal membrane oxygenation in adult patients: a systematic review and meta-analysis

Platelets and extra-corporeal membrane oxygenation in adult patients: a systematic review and meta-analysis

Thrombocytopenia and extracorporeal membrane oxygenation in adults with acute respiratory failure: a cohort study

Heparin-induced thrombocytopenia during extracorporeal life support: incidence, management and outcomes

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